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Intermittent Urinary Catheters

31 January 2013

Over the last few years, the use of intermittent catheters for patients unable to completely empty their bladder has increased. This is not a new procedure and is believed to have been undertaken some 3000BC years ago for short-term relief when voluntary urination was not an option or was proving to be difficult. In 1806, Sir Everard Home recommended intermittent catheterisation to be the preferred method of emptying the bladder.  This has not changed in more than two centuries.⁵⁵ 21st Century Catheter Project (2011)

Intermittent catheterisation involves the placement of a catheter into the bladder temporarily in order to drain away urine followed by immediate removal and disposal or cleansing and drying of the catheter for reusing, depending upon which type is used.  It is the preferred method of catheterisation in patients with bladder dysfunction and is referred to as the 'gold standard'.⁵⁶´⁵⁷⁺⁵⁸ Mangnall J, Carver, Winder Since the risk of developing a urinary tract infection is reduced compared with that of an indwelling catheter, intermittent catheterisation should be considered in preference to an indwelling catheter.⁵⁹´⁶⁰´⁶¹⁺⁶² NICE Guideline CG97 (2010); NICE Guideline CG139 (2012); EAUN (2012); SARI (2011)
Various tubing materials have been used for the intermittent catheterisation procedure ranging from onion leaves to catheters made from silver, stainless steel, polyvinyl chloride (PVC) or silicone as developments occurred.

Today, disposable single-use intermittent catheters are more advanced with the development of coated and prelubricated catheters.  Different coatings available are added to the surface of the PVC or silicone tubing in order to ease insertion.   The gentle passage of a coated or prelubricated catheter into the bladder, if undertaken correctly,  is smoother and safer thereby reducing the risk of trauma along the way.  However, non-coated, single patient use intermittent catheters are also available which are made from either PVC, silver or stainless steel for female use only. These should be used with a separate lubricating jelly for ease of insertion and to prevent trauma. These can be washed with tap water and dried immediately with a clean dry cloth.  

Adult intermittent catheters are available in a standard (male) length (40-45cm) and a shorter female length (20-26cm).  For children, paediatric standard length catheters (approximately 30-31cm) are available but if a child requires a size 12ch then a  standard (male) or female length catheter should be used.⁵² Robinson 2001

The NICE Clinical Guideline CG139 (2012)⁶⁰ NICE CG139 (2012) points out that long term intermittent catheterisation (more than 28 days) is being undertaken in the community.  As such, it is important that the choice between intermittent catheters should be informed by robust evidence on clinical and cost-effectiveness, bearing in mind that the individual patient's comfort and quality of life should be considered.  Although, the evidence using the NICE cost-effectiveness model showed that reusable non-coated intermittent catheters were the most cost effective option, the clinical evidence informing this model was of low to very low quality.

With regards to primary outcome measures, the NICE CG139 (2012)⁶⁰ NICE CG 139 (2012) recommends symptomatic UTI's; UTI associated bacteraemia; mortality; patient comfort and preference; quality of life; clinical symptoms of urethral damage and costs.

Whatever type of intermittent catheter is selected, it is the patient who should decide which one is the most comfortable and manageable once a comprehensive assessment has been completed.  (See figure 6)


(Figure 6)   Intermittent Urinary Catheters


Classifications

•    Intermittent Self Catheterisation (A clinically clean procedure undertaken by the patient)
•    Intermittent Catheterisation (A clinically clean procedure undertaken by a relative or carer)
•    Intermittent Catheterisation by Healthcare Professionals (A sterile procedure undertaken in an acute or emergency situation before decisions are made about future management)⁵⁶ Mangnall J (2006)

Studies have  shown that undertaking a clinically clean procedure as opposed to a sterile procedure does not increase the risk of infection.⁶⁰´⁶³´⁶⁴⁺⁶⁵ NICE  CG139 (2012), Robinson (2006), Pratt et al (2007) & Lemke et al (2005)

Indications

•    Chronic Urinary Retention
(Mainly caused by bladder outflow obstruction due to congenital abnormalities; benign prostatic hyperplasia; prostatic carcinoma, pharmacologic reasons eg Botulinum toxin type A and anticholinergics; urethral strictures; or iatrogenic causes ie following pelvic surgery)

Chronic urinary retention is subdivided into low pressure chronic retention and high pressure chronic retention:

Low Pressure Chronic Retention

Low pressure chronic retention is the term used when bladder pressures remain within the normal range before and after filling. The detrusor remains capable of expanding during the filling stage, but is not able to fully contract and empty the bladder.  As long as there is no threat to kidneys surgery should be avoided as there are no real benefits to surgical intervention.⁶⁶ Negro CLA & Muir GH (2012)  In those with low pressure retention and detrusor underactivity surgery has been found to be no better than catheterisation for outcomes.⁶⁷  Thomas AW et al (2005) Although some individuals may remain symptom free despite having a post void residual volume of urine, others with low pressure retention may experience symptoms including hesitency, slow stream, a feeling of incomplete bladder emptying,  frequency and UTI's.  Conservative management depends upon the individual's symptoms and may include advice on possible intermittent catheterisation, how to  double void,  and, if indicated, appropriate antibiotic treatment.  

High Pressure Chronic Retention

High pressure obstruction can lead to changes in the bladder causing further problems such as trabeculation, diverticuli, thickening of the bladder wall, ultimately leading to detrusor muscle failure.  High intravesical pressure on the ureters and kidneys may cause hydroureter and hydronephrosis ultimately leading to renal impairment.²⁰   JASSIM Y & ALMALLAH Z (2009)

•    Continent Catheterisable Urinary Stoma
The Mitrofanoff procedure creates a continent catheterisable channel between the bladder and the skin of the abdomen using the disconnected appendix or a segment of the small intestine.  Intermittent catheterisation is undertaken through the abdominal stoma to drain urine from the bladder, thus avoiding the need to wear an ostomy bag after bladder removal (Cystectomy).  Another surgical procedure that does not require the patient to wear an ostomy bag is a bladder enlargement known either as a Bladder Augmentation or Cystoplasty.

•    Dilating Urethral Strictures
Intermittent drainable catheters are commonly used to dilate urethral strictures in the region of the bulbous urethra.  However, for strictures lower down in the urethra, ie meatal or distal penile urethra, small length dilaters that do not drain urine are ideal.  Depending on medical instruction, small Charriѐre (Ch) size catheters are initially used ie 10ch or 12Ch  following which the size is graduated  to a 14ch, 16ch or even bigger.⁶⁸ Robinson J 2007
 
Charrière (Ch) size is the term used for the French Gauge (Fr) measuring unit, named after its inventor, Joseph-Frédéric-Benoît Charrière.  Intermittent catheters, like indwelling catheters, are made in a variety of Charrière (Ch) sizes.  1 Ch is equal to 0.33mm diameter.  This means, for example, that a 12Ch catheter is 4mm and a 16Ch catheter is 5.3mm in diameter.⁵²´⁶⁰⁺⁶³  Robinson  2001, NICE (CG139) 2012, Robinson 2006  

Patients undertaking urethral dilatation should be advised that they may experience pain, bleeding, infection and recurrent strictures and to inform the healthcare professional of any concerns inbetween and during clinical evaluation appointments.

Symptoms  (Possibly all but not necessarily so)

•    Urgency
•    Frequency
•    Hesitancy
•    Sensation of incomplete voiding
•    Needing to void again after micturating
•    Post-micturition Dribbling
•    Nocturia
•    Onset of nocturnal enuresis
•    Lower abdominal discomfort
•    Recurrent UTI’s


Advantages

•    Improves self care and independence⁶⁹ Wexford 2003  
•    Reduces risk of urethral trauma and urinary tract infection⁶⁴⁺⁶⁹* Pratt 2007; Wexford 2003
•    Eliminates problem of catheter encrustation⁶⁹ Wexford 2003
•    Improves body image and expression of sexuality⁶⁹ Wexford 2003
•    Can improve quality of life compared to an indwelling catheter although more evidence is needed to this effect⁶⁹ Wexford 2003
•    Reduces intravesical bladder pressure improving detrusor circulation and also protects renal function⁷⁰ Rantell (2012)   

Complications

(These occur infrequently but should be considered when discussing this option with individuals and seeking their consent, teaching the procedure and during patient evaluations)

•    Urinary Tract Infection  despite introducing a ‘foreign body’ into the bladder which could cause a UTI, evidence shows that the risk of this is actually reduced by  emptying the bladder with an intermittent catheter (usually undertaken 1-4 times per day).
•    Urethral Bleeding (mainly blood seen just on the tip of the catheter)
•    Bladder Calculi
•    Urethritis
•    Urethral Strictures
•    Fistula formation
•    Urethral false passages
•    Epididymo-orchitis

Procedure

The Skills for Health standard CC06 "Enabling Individuals to Carry Out Intermittent Catheterisation (IC)"⁷¹ Skills for Health (2010) highlights how important it is for healthcare professionals to be skilfully competent in assessing the individual's ability to perform IC ie that it is the best option, that adequate manual dexterity, co-ordination and motivation is apparent and facilities and the environment is conducive to undertaking IC. Explaining the relevant aspects of catheterisation and helping individuals to carry out the IC procedure are given equal undisputed status.  These necessitate healthcare professionals to ensure they have appropriate education and understanding of relevant aspects of competency ranging from legislation, guidelines, policies and protocols; to ensuring individual practitioners work within their sphere competence; documentation and record keeping; anatomy and physiology; acquiring and disposing of catheters as well as other issues covered within this and the patient and their carer's webpage sections.

CLICK ON PATIENTS & CARER'S section for additional topics specifically written for them and which you should be knowledgeably prepared for when introducing and teaching them how to competently undertake the procedure.

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